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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable,Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY j; to J ,tu= to ci L. Application is hereby made to the San Joaquin Local Health District fora.permit to construct and/or install the work herein described,This application is made in compliance wit San�lJoaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address [C.f t° i City/Town Owner's Name Phone 'Address �tZ 7 7 0 CA 1— f fflct City a Contractor's Name (wa-fner �4 I t"tt License# 5191 Business Phone Contractor's Address d` -S` J-WSK E Emergency Phone `Y Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _._._ No r, TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION[]— DESTRUCTION❑- Gv WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank j 0 Sewer Lines "` Pit Privy Sewage Disposal Field 10 C7-f7 Cesspool/Seepage Pit Other Property Line Private Domestic Well __ Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation r ADOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing t� 0 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATIONGRAVEL PACK Depth of Grout Seal d C1CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information S7 ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor + Type of Pump H.P. I PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth -Describe Material and Procedure _ s I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.' K Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"l certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout In ec11 priouto grouting and a final inspection. �' x Signed X Title: Date: 77/"f (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I i f � � a Application Accepted By t Date Additional Comments: I _ } Phase 11 Grout Inspection Phas I Final Inspection Inspection By Date Inspection By Date �~ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By.January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ t` REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE t r +T LESS PRORATION PLUS - -- - - PENALTY' OTHER Y4 OTHER Received Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE-,P.O.Box 2009 STOCKTON,CA 96201